Provider Demographics
NPI:1902844483
Name:KNOBLAUCH, GREGORY M (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:M
Last Name:KNOBLAUCH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:10100 E SHANNON WOODS ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-4104
Mailing Address - Country:US
Mailing Address - Phone:316-219-8299
Mailing Address - Fax:316-219-5899
Practice Address - Street 1:10100 E SHANNON WOODS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-4104
Practice Address - Country:US
Practice Address - Phone:316-219-8299
Practice Address - Fax:316-219-5899
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS15-00484363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS042940OtherBLUE SHIELD
KS100357590CMedicaid
KS662341OtherFIRST GUARD
970028120OtherR. R. MEDICARE
KS4840OtherPREFERRED HEALTH SYSTEMS
KS4840OtherPREFERRED HEALTH SYSTEMS